practice guidelines for managing health information
THE AHIMA FOUNDATION has established competencies for
health information management (HIM) professionals, including clinical documentation improvement (CDI) practice, as part
of an effort to establish new curricula and teaching methods for
college and university HIM programs throughout the United
States. 1 For example, as HIM programs become increasingly sophisticated, educators can use “unfolding” case studies, which
can foster “a learner-centered classroom, where the student is
actively engaged in the learning process. In this format, information is presented in several stages. At each stage, the student
engages in critical thinking and problem solving.” 2
Critical Thinking Defined
Critical thinking involves the following key tasks: 2
Considering what is not there
Thinking “outside the box”
To accomplish these tasks, the critical thinker must be open to
new information, alternative explanations, and unbiased consid-
eration of what one presumes to be true about a given situation or
problem before a conclusion is reached. “The primary difference
between thinking and thinking critically is the added dynamic of
having a purpose and control for the thought process.” 4
Thinking critically requires more than criticism of the current
state of affairs. Rather than a negative activity, it is a positive
process developed to identify effective solutions to complex issues. Potential steps to critically consider a positive solution to a
complex problem include:
Gather and analyze information.
Develop a set of assumptions as a basis for the thought process.
Use scientific methods to develop conclusions.
Discern the validity of knowledge sources using questions
Apply a creative thought process to develop possible solutions.
Analyze the feasibility, advantages, and disadvantages of
Determine necessary action.
Positively communicate a proposal to stakeholders.
Implement best-practice solutions.
The use of critical thinking allows for confidence through success, independent action, collaboration when needed, and effective, creative solutions that improve job satisfaction. 5
Why Is Critical Thinking Necessary in Healthcare?
Critical thinking skills are necessary in today’s healthcare environment because of the complexity of the industry. Healthcare professionals must apply analytical skills to make complex
decisions for high-quality patient care delivery. The intricacies
of the electronic health record (EHR) and associated interoperability issues have added a layer of complexity for providers
and healthcare workers. The internet has exponentially increased the amount of information on any subject, resulting in
the specialization and subspecialization of today’s providers,
clinicians, and nonclinicians. Historically, there may have been
one professional performing a combination of functions such
as HIM management, quality assurance, utilization review, and
CDI activities; today, however, each of these functions is typically performed by a specialist in that area.
Critical thinking skills are an area of focus for many healthcare managers as they encourage their staff to think through
problem solving at a higher level. Traditionally, clinical documentation specialists (CDSs) may have been selected for CDI
positions based on their clinical expertise. Today’s CDI team
members must be competent in many other areas. CDI managers are calling for more highly skilled thought leaders who not
only learn their specific area of expertise but also keep abreast
of current research in interrelated areas in order to tie together a
bigger picture of issues they face on a daily basis. The outpatient
CDS should therefore learn about the organizational goals and
objectives, budget issues, staffing constraints, key performance
indicators, and strategic plans that affect the outpatient CDI areas during the day-to-day problem-solving process.
Critical thinking skills allow the CDS to become a transformational leader who can do the following:
Challenge preliminary solutions. Example: The outpatient CDS has been the key CDI staff member on the new
outpatient CDI pilot clinic implementation. They understand that the hospital has been closely monitoring budgets
because of a downturn in revenue related to the increase
in risk-based payer plans. The initial plan for the CDI program rollout to additional clinics involved adding one outpatient CDS to each site. After working on the initial clinic
Clinical Documentation Improvement for
Outpatient Care: Design and Implementation
Editor’s Note: This Practice Brief is based on an excerpt from the AHIMA Press publication Clinical Documentation Improvement
for Outpatient Care: Design and Implementation by Pamela Carroll Hess, MA, RHIA, CCS, CDIP, CPC.